MEDICARE: VERNIECE GREEN-FULFORD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	010838	NY

General Provider Information

NPI Number	:	1699171728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VERNIECE GREEN-FULFORD

Provider Business Mailing Address
First Line	:	2744 HYLAN BLVD # 116
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-4658
Country	:	US
Telephone Number	:	929-333-6905
Fax Number	:	929-566-8627

Provider Business Practice Location Address
First Line	:	360 NEW DORP LN STE C
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-3035
Country	:	US
Telephone Number	:	929-333-6905
Fax Number	:	929-566-8627

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2014
Last Update Date	:	07/25/2022

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